After teaching surgical implantology for over 30 years, I have yet to meet a dentist who I thought couldn’t learn to place dental implants. Implant placement is not a difficult clinical procedure as long as the correct case is selected. Difficult implant procedures usually result from a dentist “pushing the envelope” or not adhering to basic treatment planning and clinical principles. It is truly my belief that all general dentists have the skills needed to place implants and should integrate oral implantology into their practices. A recent survey found that over 98% of Misch International Implant Institute graduates are placing implants on a routine basis, and on average, they have increased their gross practice production by 23% in the first year of training. One stumbling block for many general dentists is simply how to get started. In this post, I will outline five basic steps that will help general dentists implement dental implants into their practice.

Dental implantology continues to be one of the fastest growing areas in medicine today, and studies have shown that this trend will continue at a record pace over the next decade. Unfortunately, most dentists who graduate from dental school leave with very minimal exposure to the various aspects of dental implant education. Therefore, most general dentists who are interested in incorporating dental implants into their practices must also obtain dental implant training. Here are several outlets that offer dental implant courses and educational services:

2. Study Clubs: This education opportunity, like the Glidewell Online Study Club, is usually presented by local dental societies or dental groups that bring in different lecturers on various topics in oral implantology. These types of educational venues tend to be excellent supplements to previous educational foundations.

Dental implantology continues to be one of the fastest growing areas in medicine today, and studies have shown that this trend will continue at a record pace over the next decade.

3. Webinars: One of the most recent, and highly successful, opportunities to grow your implant expertise is webinars. Viewers can hone their implant knowledge through a collection of videos like the Hahn^™ Tapered Implant System Webinar Series. The Misch Institute also offers webinars where participants can submit questions and utilize various interactive tools concerning the presentation.

4. Blogs, Social Media and Podcasts: A dental blog, like the Smile Bulletin blog from Glidewell, is a resource for reading updated information on a regular basis concerning various opinions and information on dental implants. On social media, there are platforms like the Misch Instagram account, which serves as a way for likeminded dentists to learn and advance together. Similarly, podcasts can bring to light some of the challenges dentists face in their practice. The “Chairside Live: Dental Insights” podcast, for example, discusses the latest advances in dentistry with top clinicians in the field.

5. Current Literature Publications: These include current articles on any subject in dental implantology. Various search engines, such as Google Scholar or PubMed^®, offer free services and allow topics and date ranges to be modified to refine your search.

6. Textbooks: Books that have been written on various subjects in oral implantology are vital for increasing your knowledge of implant placement and related topics. The most rewarding part of my teaching career over the years has been the feedback I receive from dentists all over the world concerning my two recent textbooks: “Misch’s Avoiding Complications in Oral Implantology, 1st Edition” and “Contemporary Implant Dentistry, 4th Edition.”

7. Hands-On Courses: This type of dental implant course has become very popular. Doctors can travel to a location and perform various types of hands-on exercises or live implant procedures on patients. This allows clinicians to obtain the necessary skills to develop and implement different procedures into their practice.

8. Continuum Courses: These usually consist of multiple courses that are progressive in nature and tend to encompass all aspects of dental implantology. This has been the most popular type of dental implant training over the years and the most comprehensive. The Misch Institute is the oldest and most successful continuum program, having trained approximately 8,000 doctors over the last 35 years.

In summary, dental implant education is a continual, lifelong process. It is constantly evolving with new technological advances. I recommend, especially during the early portion of your learning curve, that you look into weekend courses, webinars and study clubs, which are good places to start. However, a comprehensive implant continuum is highly recommended so you can obtain an up-to-date, broad-based education on all facets of implantology. These types of courses will allow you to develop a strong foundation of dental implant principles, which ultimately leads to successful and predictable patient care.

I often tell our students, “If you perform restorative dentistry procedures in your office, you can definitely learn to surgically place dental implants.” As with any type of dental treatment, there are varying levels of case difficulty. The key to adding implant placement to your dental practice is to learn and understand which cases are easy and which are difficult. You can accomplish this by learning to use proper clinical principles in the case selection and treatment planning process. At the Misch Institute, we have developed the curriculum to allow clinicians to predictably gain the confidence and skill set to integrate various implant-related procedures into their practice. For example, we teach surgical procedures in a progressive manner. The skills acquired in learning atraumatic extraction techniques enable clinicians to easily implement socket grafting protocols into their workflows. This will eventually lead to single-implant placement, followed by multiple sites and then completely edentulous arches.

When evaluating implant sites, clinicians must understand that there is a wide range of implant difficulty, from easy, such as a maxillary first premolar, to difficult, such as a mandibular second molar. Usually, we encourage doctors to start their implant journey in specific sites.

For doctors who are just starting their implant journey, I often recommend beginning with maxillary first premolar edentulous sites. In most first premolar sites, there exists sufficient height and width of bone. In addition, this area is rather easy to surgically operate on, as the visual field can be directly seen, and bleeding or anatomy, such as the tongue or floor of the mouth, do not complicate the procedure.

Mandibular Posterior Molars: Even though this area may appear to be an easy place to insert an implant, the clinician should always be concerned about the location of the mandibular nerve. In addition, this area may be highly susceptible to lingual perforations from sublingual undercuts. Lastly, access may be difficult because of the posterior location.

Maxillary Anterior: This area is usually compromised in bone quantity, as the buccal plate is the thinnest here, even in healthy patients. Ideal positioning is very difficult to obtain, especially since the trajectory often makes implant positioning more buccal.

Maxillary Posterior: The maxillary posterior area is historically associated with the weakest and poorest bone density. In addition, placement is often complicated by the location of the maxillary sinus, making surgical access difficult at times.

Immediate Implants: Extraction and immediate placement of implants may be very difficult in some cases. Immediate implants require an additional skill set, and treatment planning is more complicated. In my textbook “Contemporary Implant Dentistry, 4th Edition,” I have developed a difficulty scale for each specific tooth, dictated by various factors.

Clinicians can also learn bone grafting techniques via the same protocols. With respect to socket grafting procedures, doctors are encouraged to first graft five-walled sockets, where all bony walls are present, then venture into more complex socket grafting procedures such as four-walled sockets, which are usually missing the buccal wall. The experience and confidence gained in completing these procedures will then lead into ridge augmentation procedures. At the Misch Institute, we have various ridge classifications, classified mainly according to difficulty. This type of learning has allowed doctors with very minimal surgical experience to gain the necessary skills to treat most types of implant cases.

One of the most significant technological breakthroughs in implant dentistry has been the advent of cone-beam computed tomography (CBCT). A CBCT examination allows the clinician to more accurately determine available bone quantity and quality, as well as to create an ideal prosthetic treatment plan for the case. Knowing the exact bone morphology and location of vital structures prior to the surgical procedure allows for safer and more accurate implant placement. This technology has also led to the use of guided implant surgery, which allows the clinician to place implants in an ideal position in relation to the intended final implant prosthesis. This is based on three-dimensional, interactive treatment planning prior to surgery.

Today, there are numerous options for dentists to obtain CBCT scans for their patients. Fortunately, over the years, CBCT units have become more affordable and accessible. Here are some ways you can incorporate CBCT technology into your practice.

1. Purchase a CBCT Unit. Purchasing a CBCT unit is most commonly the largest capital investment that an implant dentist will make in their practice. There are two ways to obtain an office-based CBCT unit:

   • New CBCT Unit: There are numerous high-quality scanners on the market today. Most CBCT scanners from larger, well-established companies have long track records, and the companies can service the unit if needed. Caution should be exercised in buying off-brand CBCT units: These units are often less expensive, but their long-term maintenance and longevity are unpredictable. The price range for a new CBCT unit is approximately between $70,000 and $150,000.
   • Certified, Pre-Owned CBCT Unit: This relatively new option often costs about 30%–50% less than brand-new systems. However, care should be exercised when deciding where to purchase a pre-owned unit. My recommendation is Renew Digital, which has been in the business a long time and is very reputable. This company installs CBCT units with long track records and the latest dental imaging software. Usually, these pre-owned machines come with new software and a full warranty.

Knowing the exact bone morphology and location of vital structures prior to the surgical procedure allows for safer and more accurate implant placement.

Note: For dental implant purposes, a medium field of view (FOV) is recommended. With medium FOVs (8 x 8 cm), both arches may be captured on the scan and surgical guide fabrication is easily accomplished. Smaller FOVs (5 x 5 cm) are mainly for single edentulous spaces and are difficult to use for larger areas. Larger FOVs (17 x 23 cm) depict unnecessary anatomical areas unrelated to implant placement and usually are indicated for orthodontics or craniofacial applications.

2. Refer Patients for CBCT Scans

   • Refer to Another Office: Doctors can refer their patients to other clinicians in their area who have CBCT units. However, some doctors are reluctant to take CBCT scans for other doctors because of potential liability issues.
   • Refer to Hospital or Scanning Center: Referring patients to a hospital or scanning center may be challenging in some cases. Oftentimes, this option is more expensive, and receiving scans in a timely manner may be difficult.

Utilizing CBCT technology with the fabrication of surgical guides allows the clinician to place implants in a safer and more precise location. Generally, there are three different types of surgical guides that may be fabricated for use:

1. Pilot Guide: A surgical template that allows the clinician to drill the first osteotomy site to depth, the pilot guide allows for ideal position and angulation per the preoperative CBCT scan. Subsequent drills are used via the freehand method.

2. Universal Guide: This surgical guide may be used with any type of implant system. All drills, except for the last drill, are used with the guide. The last drill is designated for freehand use with the surgical kit of the implant system.

3. Fully Guided: A fully guided surgical guide allows for all drills to be used via the surgical guide along with the placement of the implant.

Navigational or dynamic surgery has been used for many years in other medical fields and has been recently integrated into dental implant surgery. This technology allows clinicians to place implants with a very high accuracy that is based on three-dimensional and prosthetically driven plans. Positioning is dictated by real-time feedback with the advantages of a streamlined digital workflow, improved surgical visualization, and adaptability to intraoperative anatomy and conditions. Today, one of the most common and most successful navigational units in implant dentistry is Navident.

In the past, I would have definitely agreed with the statement that implant dentistry is expensive to get started with: The implants themselves, prosthetic parts, lab fees and education alone can be costly expenses. For many years, it was very disheartening to see doctors receive extensive dental implant training but not be able to purchase the proper armamentarium because of financial reasons. Thankfully, through our partnership with Glidewell, our Misch attendees can now get started in implant dentistry with a very modest initial investment. Glidewell has allowed our graduates to obtain everything they need to start placing implants, including implant motors, surgical handpieces, Hahn™ Tapered Implant Surgical Kits and Hahn Tapered Implants, for an investment that is far less than what they would have paid in the past. In addition, Glidewell offers a 20% discount on the laboratory work for cases in which the Hahn Tapered Implant System is used. In my opinion, there has never been a better time to get started in the field.

When doctors are just getting started in the implant field, it’s easy for them to overspend and buy instruments they will rarely use. Most dental offices have the essential instruments for basic extraction, socket grafting, implant placement and bone grafting procedures, but supplemental instruments may also be purchased to augment the existing instruments. An inexpensive and simplified option is to purchase the Newport Surgical Implant and Bone Grafting Instrument Kit, which includes the essential instruments needed to complete the bone grafting procedures typically performed in the dental practice for a reasonable price. More information on necessary implant instruments and surgical armamentarium can be found in Chapter 26 of “Contemporary Implant Dentistry, 4th Edition.”

The recommended surgical supplies needed to perform dental implant and bone grafting procedures are as follows:

1. Irrigation: I prefer to purchase 500 mL bags of 0.9% sodium chloride (sterile saline).

2. Gauze: Use non-woven gauze, not woven gauze. Non-woven gauze is stronger and has more absorbency with less lint than woven gauze.

3. Surgical Blades: #15 carbon steel surgical blades are most ideal for dental implant procedures. An alternative option is a #15c blade, which has an extended cutting edge and is advantageous for difficult access areas.

4. Sutures: An incision line opening is the most common postoperative complication after dental implant or bone grafting procedures. My strong recommendation for a “universal” suture that may be used in all conditions is polyglycolic acid (PGA). PGA is an excellent absorbable material with a prolonged tensile strength. This suture does not readily harbor bacteria (wicking), has minimal tissue reactions and is relatively inexpensive.

It is paramount that you select a system backed by a reputable company that will be in business in the future. I hear too many stories of doctors using an implant system because of low costs, only to be unable to acquire parts later on. Therefore, do not place yourself or your patients at risk.

In my opinion, the best deal in implant dentistry is the Glidewell bundle packages for the Hahn Tapered Implant System. I know Glidewell always has affordable intro packages for dentists who call the Glidewell Direct team at 888-303-3975. Not only do they give you a quality motor and handpiece from Aseptico, but you also obtain a large inventory of implants that allows you to start placing implants with a very modest investment. The ability to have multiple implants of different diameters and lengths is very advantageous. Too often, doctors call me in the middle of their implant surgery and relate how they had to modify their intended surgical plan by placing an implant of a different size, but in some cases, they don’t have the correct size readily available.

Almost daily, I receive emails from doctors asking me about a particular type of bone grafting material. There are an endless number of options with respect to grafting material: autograft, allograft, zenograft and alloplast, for example. My recommendation for doctors just beginning their implant journey is to use a material that is affordable and more universal for all types of procedures, like socket grafting and small ridge augmentation procedures. This material is an allograft, which is very affordable and predictable. It is advantageous because it is mineralized (osteoconductive) and thus maintains space, and it has the mutual benefits of a cortical and cancellous blend. The cortical component allows the graft material to be excellent at maintaining space, and the cancellous component allows bone cells to readily adhere and assist in the regenerative process. In addition, the 250–1,000 micron size has been shown to resorb in a timely fashion for ideal bone formation.

Similar to bone grafting materials, a full array of membranes can be found on the market today. The most common and economic type of membrane is a collagen membrane. My recommendation would be to utilize the Newport Biologics™ membranes, as they are very affordable and have the benefit of ease of handling. Their products include collagen plugs for extraction sites and socket grafting, regular collagen 3–4 months for use in small ridge augmentation procedures, and extended collagen 4–6 months for larger bone defects and ridge augmentation procedures.

I am often asked, “Where do you find implant patients?” The best place is your existing patient base. General dentists see potential dental implant patients every day in their offices and may not even know it. With the predictability of dental implants in dentistry today, it is no longer acceptable to be doing “heroic” treatment for teeth with a poor prognosis or heavy damage.

It is imperative that dentists learn to explain the benefits of dental implants to their patients, along with the disadvantages of any alternative conventional treatment plans. For example, when a single tooth is lost, there are many benefits to placing an implant instead of preparing the adjacent teeth for a fixed partial denture.

Studies show that an abutment tooth prepared for a crown has an approximate 14% chance of developing irreversible pulpitis, which would necessitate endodontic therapy. This often leads to increased costs for the patient or a loss of patient confidence in the doctor. Ten-year survival rate studies show an implant prosthesis has a survival rate that is over 25% greater than that of a fixed partial denture supported by natural teeth. Almost all dental implant survival and success studies report a success rate for dental implants that is greater than 95%, which is much higher than any other type of nondental implant that is placed in the body.

Not only does the dentist have to be 100% committed to incorporating implants into their practice, but so does their dental team. The dental team, especially hygienists, are in an ideal position for promoting dental implants to the patients. However, the dentist must train and educate the team in all aspects of dental implant procedures. If the staff is excited about dental implant treatment, then often they will educate the patients on the benefits of implant treatment. The Misch Institute gives a “Team Training” educational course once a year, which is specifically for front office staff, assistants and hygienists.

By incorporating dental implants into your office, your practice will change in many ways. I often hear from our graduates that dental implants have “broken up the monotony of a general practice.” Most commonly, it becomes a break from the “drill and fill” procedures that are so common in offices. Surgically placing implants is an easy and straightforward procedure, as long as the clinician utilizes strict knowledge and protocols for case selection.

Dental implant courses will help dentists learn the necessary principles and develop a strong foundation of concepts in dental implantology. To help simplify the treatment planning processes, incorporation of CBCT technology is becoming the standard of care. Luckily, there are numerous affordable options to use this advanced technology. When starting an implant practice, the correct surgical armamentarium must be purchased, without buying unnecessary materials. This can be easily accomplished by being practical with the type of materials purchased. Lastly, general dentists are at the forefront of obtaining dental implant patients. By committing 100% to incorporating implants into your practice, and by getting your staff on board, placing implants will be very motivating and financially rewarding to your dental career.